Project Summary/Abstract More than 1 million Americans survive acute respiratory failure (ARF) each year. These ARF survivors often endure health-related quality of life, physical, psychological, and cognitive impairments in the months following discharge. This growing public health and morbidity burden associated with ARF survivorship stems, in part, from the fact that the robust evidence to guide best practices during mechanical ventilation is unmatched by similar evidence to guide care after the intensive care unit (ICU) stay. Because 90% of ARF survivors transition from ICUs to general hospital wards during their recoveries, the quality of ward-based care may strongly influence patients? outcomes. However, the methods needed to assess and improve ward systems practices for ARF survivors do not exist. The candidate?s Master of Science in Clinical Epidemiology (MSCE) and F32 work defined the construct of ?ward capacity strain,? which occurs when demand for clinical resources exceeds availability. This work identified measures of ward patient volume and staff workload that contribute to ward capacity strain, and demonstrated that increased strain was associated with prolonged ICU discharge wait times and 30-day hospital readmissions among critical care survivors. This Career Development Award builds from that work, and seeks to achieve three aims that, together, will promote the candidate?s long-term goal of developing and testing strategies to improve ARF survivor outcomes by mitigating ward capacity strain and other systems-level factors. Specifically, in this award the candidate seeks to measure associations of ward capacity strain with (1) in-hospital outcomes and (2) post-hospitalization, patient-centered outcomes among ARF survivors, and (3) identify care processes that mediate relationships between ward capacity strain and patient outcomes, and ward-level systems practices that modify such relationships. To complete these aims the candidate will perform a retrospective cohort study (Aim 1), a prospective longitudinal cohort study enrolling 176 ARF survivors (Aim 2), and a mixed-methods positive deviance study enrolling 50 ward-based clinicians who care for survivors of ARF (Aim 3). The hands-on experience she will acquire in completing these three studies using different methods will be complemented by carefully selected didactic coursework and structured mentoring by senior investigators from multiple disciplines. This work will lead to pilot grants and an R21 to support development of an intervention to mitigate the untoward effects of ward capacity strain on ARF patients? outcomes, and to an R01 to support a randomized controlled trial of this intervention. Completing this research will build upon the candidate?s past training, which includes an MSCE obtained with NHLBI T32 support and an NHLBI F32-supported post-doctoral fellowship, and will provide her with the protected time and experience to achieve her career goal of becoming a leading, independently-funded outcomes researcher focused on leveraging systems-level practices to improve outcomes among survivors of ARF and other critical illnesses.